OF mental health care and mentally ill

Techniques to identify misinterpretations and unhelpful ideas

The first stage in cognitive restructuring is to identify the content and occurrence of thoughts associated with a problem and rate (a) the person’s conviction in them, and (b) the person’s feelings and responses to them. This could be achieved in several ways: •Keeping thought-monitoring records for a specific period of time, detailing the situation that a thought occurred, what the thought or range of thoughts were, how the person felt and responded at the time, and how much the person believes in that thought. The purpose of thought records is to identify a person’s idiosyncratic misinterpretations or unhelpful ideas, establish a pattern of occurrence, demonstrate the link between thoughts and a person’s feelings and responses, and finally rate the person’s belief in them.

An important point to remember while keeping a thought record is to identify which thoughts are the most potent and relevant ones by asking, ‘If we could make one or two thoughts go away, which ones would you choose in order to make a real difference in the way you feel?’ •Going through a recent incident when the person experienced emotions or symptoms associated with the problem. Starting questions could be, ‘When was the last time that you felt miserable/ angry/anxious/scared?’ or ‘Looking back during the last week, which was the worst day for you. What was happening at the time that made it so bad?’ Then, questions such as, ‘What was going through your mind at the time?’ and ‘Were you saying anything to yourself at the time?’ could help elicit thoughts associated with the specific incident. •Using the ‘downward arrow technique’ which aims to elicit the meaning of one’s thoughts. The clinician starts by asking the question, ‘If this were true…’

–What would be so bad about it?

–What would this tell you about yourself/other people/your future/ your life? and carries on by asking the same question to the patient’s answer until we arrive at a statement which reflects a core belief or personal assumption. An example is given below:

I am worried I am becoming mentally ill.

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If this were true (you became mentally ill) what would be so bad about it?

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I would end up in a hospital.

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If this were true, what would be so terrible about ending up in a psychiatric hospital?

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Everyone would know and also I would never work again.

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If this were true, what would be so bad about it?

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Everyone would look down on me, feel pity on me and eventually abandon me.

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If this were true, what would this tell you about your life?

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Life will not worth living if I end up without a job and friends. The downward arrow technique, otherwise referred to as inference chaining, could yield potent thoughts and powerful emotions which represent the person’s ultimate fears. Therefore, this technique should be used only if the practitioner is sure about ‘what to do’ with the statement that lies at the end of the arrows. Some useful examples of applications of the downward arrow technique are described by Greenberger and Padesky (1995) for anxiety and depression, and Turkington and Siddle for delusions.